CMS Pub. 100-04, ch. 30, § 30.2.3

When an item and/or service furnished do not meet locally acceptable standards of

practice, the healthcare provider or supplier is considered to have known that Medicare

payment would be denied. Because healthcare provider and supplier licensure is

premised on the assumption that they are knowledgeable about locally acceptable

standards of practice, healthcare providers and suppliers are presumed to have knowledge

about locally acceptable standards of practice for liability determinations. No other

evidence of knowledge of local medical standards of practice is necessary.

In order to determine what “acceptable standards of practice” exist within the local

medical community, Medicare contractors will rely on the following:

• published medical literature;0F

1

• a consensus of expert medical opinion;1F

2 and

1 “Published medical literature” refers generally to scientific data or research studies that have been

published in peer-reviewed medical journals or other specialty journals that are well recognized by the

medical profession, such as the “New England Journal of Medicine” and the “Journal of the American

Medical Association.”

2Consensus of expert medical opinion might include recommendations that are derived from technology

assessment processes conducted by organizations such as the Blue Cross and Blue Shield Association or

the American College of Physicians, or findings published by the Institute of Medicine.

• consultations with their medical staff, medical associations, including local

medical societies, and other health experts.

NOTE: A healthcare provider or supplier may indicate on the claim (via Occurrence

Code 32 or the applicable Healthcare Common Procedure Coding System code modifier

(i.e. GA, GX, ext.) on contractor claims) that they gave the beneficiary a valid written

notice before furnishing the item and/or service. In that instance, the Medicare contractor

will hold the beneficiary, not the healthcare provider or supplier liable for the denied

charges. If it is determined that the written notice was invalid, the contractor will

override the GA code, and the healthcare provider or supplier will be found liable.